Child Name *

First Name

Last Name

Ethnicity

Black/African-American

White/Caucasian

Hispanic/Latino

Asian

Other

Gender

Female

Male

T-Shirt Size

Child Small

Child Medium

Child Large

Adult Small

Adult Medium

Adult Large

Adult XLarge

Parent/Guardian's Name

First Name

Last Name

Cell Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Phone *

(###)

###

####

Agreement *

I, as the of Participant, Parent/Legal Guardian of Minor Participant, Do herby indemnify, save, defend, hold harmless, release, and forever discharge UEmpower of Maryland, it’s employees, instructors and volunteers, from any and all, present and future liability, demands, suits, actions, or claims for losses, damages, or injury, including death, sustained by the participant arising from the participant’s participation in any related city programs, activities, trips, and excursions, regardless of whether such claims, losses, damages or injuries result, in whole or part, from the negligence of the of UEmpower of Maryland, it’s employees, instructors and volunteers. This provision shall survive termination of this release and authorization. I have read and fully understand the above waiver and release of all claims. If registering on-line or via fax, my on-line or facsimile signature shall substitute for and have the same legal effect as an original form signature. By checking the box below, I as the Participant or Parent / Legal Guardian of the Participant, acknowledge and agree to the above.

I Agree

Health Info

The parent/guardian’s responsibility is to supply medication and fill out authorization forms for administration. Below please check any medical conditions that may require attention during program time.

Cancer

Diabetes

Disability

Hearing Problems

Heart Problems

Hemophilia

Physical Disability

Respiratory

Seizers

Vision Problems

Other

Myself/My child:

HAS allergies

does NOT have allergies

Media Release

I, the undersigned, authorize the staff of U Empower of Maryland and affiliated departments and organizations to record, film and videotape my voice and image and to photograph my person. I further authorize U Empower of Maryland to use, televise, and publish (in print, radio or on the Internet) such voice and image recording and photographs for any purpose which U Empower of Maryland deems suitable. I understand that U Empower of Maryland intends to advertise, market, and distribute the above-named production, and I hereby release any and all interest which I have or may hereafter acquire in any proceeds from such sale or distribution of said production. I agree that no representations have been made regarding the purpose or use of my voice or image except those set forth in this release. In consideration of participation in the media production described herein, I do for myself, my heirs, executor, administrators, legal representative and assigns release and forever discharge the agent, and employees and all other persons connected with the named production from any and every claim, demand, action, in law or equity that may arise as a result of my participation in the production named in this release. I further state that I have carefully read the terms of this release. I understand that I am signing a complete release and bar to any claim resulting from my participation in the production named in this release.

I agree